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Mentor Responsibilities
Upon request, active FACT inspectors may agree to serve as Mentors, to guide and coach Trainee inspectors through an entire inspection and accreditation process. FACT Inspectors are valued volunteers, who demonstrate the ability of effective communication and serve as model inspectors with the Trainees.
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As soon as a Mentor is assigned to a Trainee, the Mentor shall simultaneously prepare a thorough mentorship plan with the Trainee, encompassing all steps of the thorough inspection and document review, including all pre- and post-activities. A meeting with the Trainee must be scheduled in a timely manner to become acquainted with the Accreditation Portal, confirm travel arrangements, review the planned training process, and verify that the Trainee has a full understanding of the inspection process. Importantly, during this initial meeting(s), the Mentor shall provide instruction for access to the FACT portal such that the Trainee is able to complete the required Portal access training, understand the process, and review all documents in the library, previous inspection reports, and the Compliance Application Checklist. The Mentor shall provide and review the inspection timeline with the Trainee prior to the pre-inspection conference with the inspection Team and FACT Accreditation Coordinator, which is generally scheduled four weeks before the inspection to ensure completion.
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Following the pre-inspection conference, the Mentor and the Trainee shall arrange for time together to review the inspection agenda, the inspection checklist, areas of concern and preparation for the inspection including the Mentor's approach to ensure a thorough and on time on-site completion of the inspection.
During the on-site inspection, the Mentor shall share findings with the Trainee throughout the day (but not in the presence of applicant personnel) in addition to structured discussion times during the on-site lunch and prior to the exit interview.
Once the inspection has been completed, the Trainee shall complete the checklist and inspection report within three days of the inspection. The Mentor then compares the checklist and inspection summary report of the Trainee through the portal with the Mentor's checklist and summary. The Mentor reviews the Trainee's report and provides feedback to the Trainee including any inconsistencies and omissions. The Mentor will also evaluate the Trainee based on preparedness, effort, and ability to complete the training process, and document the Trainee inspection report in the Portal. Within two weeks of the inspection, the Mentor submits comments to the Trainee's inspection report and completes the Mentor evaluation through the portal. The FACT Accreditation Coordinator will invite the Trainee to join the Mentor during the Accreditation Committee meeting when the Accreditation Report is being discussed.
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Confidentiality
Inspectors must agree to comply with FACT’s Confidentiality Policy and document their agreement by completing the FACT Annual Compliance survey. Remember that all information you receive or learn as part of the inspection and accreditation process is confidential. It should never be divulged or shared with others outside of the FACT Accreditation Office or inspection team. Programs voluntarily participate in the inspection process on the basis that the information they provide is handled confidentially, and it is vital that they have confidence in the integrity of FACT and its representatives.
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Conflict of Interest
Inspectors must agree to comply with FACT’s Conflict of Interest Policy and document their agreement by completing the FACT Annual Compliance survey. If you feel that you have a potentially significant conflict of interest as an inspector, you must recuse yourself from the inspection. Examples of potential conflicts include a close working relationship with the applicant’s personnel, potential competition for referrals, and/or funding or contracts. Details of the nature of the conflict do not have to be provided to FACT. Bear in mind that each applicant has the right to refuse inspectors selected by the FACT Accreditation Office for any perceived conflict of interest. The FACT Accreditation Office will make every effort to ensure potential conflicts are resolved well before the scheduled inspection visit date. Please assist the FACT Accreditation Office by recusing yourself as soon as you determine a conflict exists.
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Ongoing Requirements
FACT is fortunate to have dedicated, long-term inspectors. Due to the evolving nature of the FACT Standards and accreditation requirements, it is necessary that inspectors’ knowledge of FACT-related issues stay current. Therefore, all inspectors are required to take an Inspector Test for each version of the Standards and answer 90% of the questions correctly.
FACT recommends that all inspectors perform at least two inspections a year. FACT depends on the commitment of volunteer experts and their willingness to participate as peers. We continuously rely on our inspectors to visit their colleagues during on-site inspections. Without this collaborative effort, FACT would not have the influence it has today.
FACT receives feedback in a variety of ways, including on-site inspection evaluations, Inspector Training Course evaluations, and written and verbal correspondence. If a trend is identified that warrants additional training, the FACT Inspector Development Committee may require inspectors to participate in additional educational activities. When this is necessary, FACT ensures that the training involves minimal time and financial resources.
Each year FACT asks all inspectors to update their credentials, contact information, and to submit new Statements of Compliance with the Duality of Interest and Confidentiality policies. Clinicians are also asked to complete a Professional History form and submit a current copy of their medical license.
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Policies and Procedures
FACT has several policies and procedures that are pertinent to inspector qualifications and the inspection and accreditation process. It is FACT’s responsibility to ensure inspectors have access to standard operating procedures (SOPs), and inspectors are responsible for complying with applicable SOPs. These SOPs are available on the FACT Website.
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Inspection Team Qualifications
While inspectors all meet the same prerequisites for being a FACT inspector, the selection of inspection teams for specific applicants depends on a variety of characteristics. The services, size, and location of an applicant impacts who is selected for an inspection team. Inspector availability for the specific dates requested by an applicant is also a consideration.
